ancillary services

6A n c i l l a r y S e r v i c e s

Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . .87

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Physical and Occupational Therapy . . . . . .110

Acupuncture and Chiropractic Guidelines . .113

Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . .114

86 www.oxfordhealth.com

Section 6 — Ancillary Services

www.oxfordhealth.com 87

Ancillary Services — Section 6

Laboratory

Through Oxford’s laboratory network, we intend toprovide you access to the tests you need to treat yourpatients, to reasonably control the increasing cost ofmedical care, and to limit your patients’ unnecessaryout-of-pocket costs.

Oxford’s outpatient laboratory network is comprised of:

• Full-service labs

• Niche labs (i.e., esoteric/specialty labs)

• Hospital labs (not all participating hospitals have participating outpatient laboratories)

Outpatient Laboratory

Policies and Procedures

• All outpatient laboratory specimens must be sent toone of the contracted laboratory as listed in thesepages and on our web site at www.oxfordhealth.com

• A referral is not required for lab specimens sent to participating laboratories (only a physician’sprescription or lab order form is required)

• When billing for laboratory services performed in theoffice, specimen handling and/or venipuncture:

• If you bill specimen handling and venipuncture codes in conjunction with a lab code, for a labprocedure performed in your office, only the lab and venipuncture codes will be reimbursed(please remember that in order for the lab code to be reimbursed, the code must be on the In-office Laboratory Testing List)

• If you bill specimen handling and venipuncture codes without a lab code, the specimen handling and venipuncture codes will be reimbursed according to Oxford’s fee schedule

• Oxford reviews laboratory ordering information on a periodic basis in an effort to support full use ofOxford’s contracted laboratory network; if our datashows a pattern of out-of-network utilization for yourpractice, we will contact you to share this informationand engage you to utilize the contracted network

Full Service Laboratories

Acu-Path Laboratories, Inc.Client services 1-888-228-7284

Bayside Diagnostics LaboratoryClient services 718-886-8500

Clinical Lab PartnersClient services 860-696-8222

Dianon Systems, Inc.Client services 1-800-328-2666

Enzo Clinical LabsClient services 631-755-5500 or 1-800-522-5052

Esoterix, Inc.Client services 1-800-444-9111

GJL Medical LabsClient services 516-326-0700 or 1-800-924-1650

Lab Corporation of America HoldingsClient services, home blood draws, STAT testing services:

New Jersey 1-800-223-0631

New York 1-800-745-0233

Connecticut 1-800-342-2475

Patient service center locator number for Members 1-888-LabCorp

Quest Diagnostics, IncorporatedClient services, home blood draws, STAT testing services:

New Jersey 1-800-631-1390

Long Island, New York 1-800-877-7530

All other New York areas 1-800-631-1390

Connecticut 1-800-982-6810

Patient service center locator number for Members 1-800-377-8448

Quentin Medical Laboratory, Inc.Client services 718-492-2600

Shiel Medical Laboratory, Inc.Client services 718-714-5700 or

1-800-553-0873, ext. 900



Specialty Laboratories

Ackerman Academy of Dermatopathology* 212-889-6225 or 1-800-553-6621

Genzyme Genetics* 1-800-848-4436

Home Healthcare Laboratory of America 1-888-522-4452

1-888-LAB-HHLA

Myriad Genetics, Inc. 1-800-469-7423

Pathology Associates, P.C.*Client services 1-800-388-3995

University Pathology, P.C.* 914-594-4150

Hospital Laboratories

Barnert Hospital*Client services 973-977-6647

Continuum Health Partners, Inc.*Beth Israel Medical Center

Pathology and Laboratory Medicine 1-800-420-LABS

Long Island Medical College*Pathology and Laboratory Medicine 1-800-420-LABS

St. Luke’s — Roosevelt Hospital*Pathology and Laboratory Medicine 1-800-420-LABS

Greenwich Hospital Laboratory*Client services 203-863-3380

Griffin Hospital*Client services 203-732-7280

Hackensack University Medical Center*Totalab 1-877-868-2522

Client services 201-996-4881

Milford Hospital Laboratory*Client Services 203-876-4256

Mount Sinai Medical Center*Mount Sinai Hospital of New York 212-241-4675

Mount Sinai Hospital of Queens 212-241-4675

Mount Sinai Hospital Clinic 212-241-4675

Mount Sinai Center for Clinical Laboratories 212-241-4675

Mount Sinai Pathology Associates 212-241-3985

Mount Sinai Pathology Consultants 212-241-8014

Mount Sinai Medical Center, Department of Dermatopathology 212-241-6064

New York University Medical Center*NYU Medical Center Laboratories 212-263-7313

NYU Pathology Associates 212-263-5475

NYU Dermatopathology Associates 212-263-7250

North Shore University Hospital — Long Island Jewish Medical Health System*Client Services:

Nassau and Suffolk counties 516-719-1000

Brooklyn and Richmond counties 718-226-5227

Participating hospitals in the North Shore system include:

North Shore University Hospital Manhasset

North Shore Hospital System Central Laboratories

Long Island Jewish Medical Center

Staten Island University Hospital

New York Presbyterian Healthcare System*New York Presbyterian Hospital:

New York Weill Center/New York Hospital Laboratories 212-746-0675

Columbia Presbyterian Center/Clinical Lab Services 212-305-2155

Columbia Presbyterian Pathologists 1-800-653-8200212-305-4840

The Brooklyn Hospital Center, Department of Pathology 718-250-8000

Laboratory of Dermatopathology, Department of Dermatopathology College of Physicians and Surgeons of Columbia University 212-305-2155

New York Community Hospital of Brooklyn, Department of Pathology and Lab Medicine 718-692-5372

New York Methodist Hospital — Outpatient Laboratory 718-780-3645

New York United Hospital Medical Center Lab 914-934-3070



New York Westchester Square Medical Center Laboratory 718-430-7300

NYHQ/Charter Diagnostics Laboratory 718-670-2575

Palisades Medical Hospital/Clinical Laboratory 201-854-5054

Wyckoff Heights Medical Center Laboratories 718-963-7519

* Provides anatomic pathology services

In-office Laboratory

Testing List

The In-office Laboratory Testing List includes codes for laboratory procedures reimbursed to physicianswhen performed in their offices. All other laboratoryprocedures must be performed by one of theparticipating laboratories in Oxford’s network.

Primary Care Physicians and Specialists

*81000 Urinalysis, with microscopy

*81002 Urinalysis, non-automated, without microscopy

*81003 Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods

82270 Blood, occult; feces screening, 1-3 simultaneous determinations

82273 Blood, occult; other sources, qualitative

82274 Blood, occult, by fecal hemoglobindetermination by immunoassay,qualitative, feces, 1-3 simultaneousdeterminations

82948 Glucose; blood, reagent strip

82962 Glucose, blood sugar by glucometer

83014 Helicobacter pylori, breath testanalysis; drug administration andsample collection (Note: Dianonprovides test kit free of charge — call 1-800-328-2666.)

83026 Hemoglobin; by copper sulfatemethod, non-automated

85013 Spun microhematocrit

85018 Blood count, hemoglobin

85651 Sedimentation rate, erythrocyte; non-automated

****86403 Particle agglutination, screen, each antibody

86485-86586 Skin tests; various

**87070 Culture, bacterial; any other sourcebut urine, blood or stool, withisolation and presumptiveidentification of isolates

**87081 Culture, bacterial, screening only, for single organisms

87177 Ova and parasites, direct smears,concentration and identification

87210 Smear, wet mount with simple stain, for bacteria, fungi, ova, and/or parasites

87220 Tissue examination for fungi (e.g., KOH slide)

****87880 Infectious agent detection byimmunoassay — streptococcus group A

89100 Duodenal intubation and aspirationsingle specimen plus appropriate test

89105 Duodenal intubation and aspiration;collection of multiple fractionalspecimens with pancreatic orgallbladder stimulation, single or double lumen tube

89130-89141 Gastric intubation and aspiration;various

89350 Sputum, obtaining specimen, aerosol-induced technique

99195 Phlebotomy, therapeutic (separate procedure)

For STAT Purposes Only, claim must be marked STAT

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

*, **, ***, **** Reimbursement is limited to one procedure (within the relatedfamily of codes) per visit.



Pediatricians Only

82247 Bilirubin, Total

Pulmonologist Only

82803 Gases, blood, any combination of pH,pCO2, pO2, CO2, HCO3 (includingcalculated O2 saturation)

Obstetricians, Gynecologists, ReproductiveEndocrinologists, and Infertility Specialists Only

82670 Estradiol

83001 Gonadotropin; follicle stimulatinghormone (FSH)

83002 Gonadotropin; luteinizing hormone (LH)

84144 Progesterone

84702 Gonadotropin, chorionic (hCG);quantitative

+89250 Culture and fertilization of oocyte(s)

+89251 Culture and fertilization of oocyte(s)with co-culture of embryos

+89253 Assisted embryo hatching,microtechniques (any method)

+89254 Oocyte identification from follicular fluid

+89255 Preparation of embryo for transfer(any method)

+89257 Sperm identification from aspiration(other than seminal fluid)

+89260 Sperm isolation; simple prep (e.g.,sperm wash, swim-up) for inseminationor diagnosis w/semen analysis

+89261 Sperm isolation; complex prep (e.g.,Percoll gradient, albumin gradient)for insemination or diagnosis withsemen analysis

+89300 Semen analysis; presence and/ormotility of sperm including Huhnertest (post coital)

89310 Semen analysis; motility and count

89320 Semen analysis; complete (volume,count, motility, and differential)

89321 Semen analysis; presence and/ormotility of sperm

+89325 Sperm antibodies

+89329 Sperm evaluation; hamsterpenetration test

+89330 Sperm evaluation; cervical mucuspenetration test, with or withoutspinnbarkeit test

+ Member must have the infertility benefit

Reproductive Endocrinologists and InfertilitySpecialists Only

89268 Insemination of oocytes

89272 Extended culture ofoocyte(s)/embryo(s), 4-7 days

89280 Assisted oocyte fertilization,microtechnique; less than or equal to 10 oocytes

89281 Assisted oocyte fertilization,microtechnique; greater than 10 oocytes

89290 Biopsy, oocyte polar body or embryoblastomere, microtechnique (for pre-implantation genetic diagnosis);less than or equal to 5 embryos

89291 Biopsy, oocyte polar body or embryoblastomere, microtechnique (for pre-implantation genetic diagnosis);greater than 5 embryos

89352 Thawing of cryopreserved; embryo(s)

Rheumatologists Only

89060 Crystal identification by lightmicroscopy with or without polarizinglens analysis, and body fluid (except urine)



Hematologists and Oncologists Only

85007 BL Smear w/diff WBC count

***85025 Hemogram and platelet count,automated and automated completedifferential WBC count (CBC)

85027 Complete WBC, automated

85097 Bone marrow; smear interpretationonly, with or without differential cell count

86077 Blood bank physician services; difficult cross-match and/or evaluation of irregular antibody(s),interpretation and written report

86078 Blood bank physician services;investigation of transfusion reaction, including suspicion of transmissible disease, interpretation and written report

86079 Blood bank physician services;authorization for deviation fromstandard blood-banking procedures,with written report

86927-86999 Transfusion medicine

*** Reimbursement is limited to one procedure per visit.

Urologists Only

89300 Semen analysis; presence and/ormotility of sperm including Huhnertest (post coital)

89310 Semen analysis; motility and count

89320 Semen analysis; complete (volume,count, motility and differential)

89321 Semen analysis; presence and/ormotility of sperm

Radiology

CareCore National Management Services, LLC, aphysician-owned radiology network comprised of leading board certified radiologists, is Oxford’s network manager for all outpatient commercial and Oxford Medicare Advantage® imaging services.Please be aware that inpatient, ambulatory surgery,emergency room radiology services, radiation therapy,radionuclide therapy, ophthalmic ultrasound, and any delegated physician arrangement are not included in this arrangement. Oxford has eliminatedthe need to submit referrals for outpatient radiologyprocedures performed by participating radiologists or radiology facilities.



Privileging by Specialty

Oxford’s privileging program is designed to improve the quality of imaging services by limiting coverage to servicesprovided in the most appropriate setting. Below is a list of imaging CPT codes for services that physicians, otherthan radiologists, can perform in their office.

Please note: The privileging program applies to office and outpatient (non-ambulatory surgery) procedures.

Privileging List* These following procedures require precertification; call 1-877-PRE-AUTH.

*** Any studies beyond three (3) require precertification; call 1-877-PRE-AUTH.

Physician Type CPT Codes Description

Primary Care Physicians: 71010-71030 Chest imagingInternal Med., Family Practice 76075, 76076, 0028T DEXA studies, bone densitometry

General Surgeons: 76942 Ultrasonic guidance for needle biopsyAIUM-accredited

Cardiologists 71010-71030 Chest imaging

78464*, 78465*, 78469* Tomographic SPECT studies

78472*, 78473*, 78494* Cardiac blood pool imaging

78478* Wall motion study

78480 Ejection fraction study

Cardiologists — Pediatric only 76825, 76826, 76827, 76828 Echocardiography, fetal

Chiropractors 72010, 72040, 72069, 72070, Spine imaging72080, 72100

Endocrinologists 76075, 76076 DEXA studies, bone densitometry

76942, 0028T Ultrasonic guidance for needle biopsy

76536 (AACE Accredited Thyroid ultrasoundEndocrinologists only)

Gastroenterologists 76975* Endoscopic ultrasound

General Surgeons, Vascular 75940 Percutaneous placement of Surgeons, Cardiovascular Surgeons IVC filter, radiological supervision

and interpretation

75952 Endovascular repair of infrarenalabdominal aortic aneurysm

75953 Placement of proximal or distalextension prosthesis for endovascular repair

Hand Surgeons 76000, 73000-73140 Fluoroscopy

Maternal Fetal Medicine 76083 Digitization of radiographic images



Privileging List (continued)


Perinatologists-Neonatologists 76092 Screening mammography

76801***, 76802***, Ultrasounds — pelvis







76830 - 76857 Ultrasounds — pelvis

76930, 76945, 76946, 76941 Ultrasonic guidance

76942 Ultrasound — pelvis, non-obstetrical

76948 Ultrasonic guidance for aspiration of ova

76075, 76076 DEXA studies, bone densitometry

OB/GYNS 76083 Digitization of radiographic images

76092 Screening mammography


76817*** Ultrasounds — pelvis

76830, 76831, 76856, 76857, Ultrasonic guidance



OB/GYNS (AIUM/ACR Accredited) 76801***, 76802***, Ultrasounds — pelvis




76820***, 76821*** Doppler velocimetry


76827***, 76828*** Ultrasounds — pelvis

Oral Surgeons 70100, 70110, 70140, 70150 Mandible and facial bone imaging

70300, 70310, 70320 Teeth imaging

70328, 70330 TMJ imaging

70350 Cephalogram, orthodontic

70355 Orthopantogram





Orthopedists 71100-71111 Radiologic examination, ribs

71120-71130 Radiologic examination, sternum

72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003, 76005 Fluoroscopies

76006 Radiologic examination, any joint

76040 Bone length studies

76066 Joint survey

Pain Management Specialists: 76000, 76005 FluoroscopyPhysiatrists, Anesthesiologists,Neurologists, and Neurosurgeons

Pediatricians 71010-71030 Chest imaging

76075, 76076, 0028T DEXA studies, bone densitometry

Podiatrists 73620, 73630, 73650, 73660 Lower extremity imaging

Pulmonologists 71010-71030 Chest imaging

Radiation Oncologists 76950 Ultrasonic guidance for placement of radiation therapy fields

76965 Ultrasonic guidance for interstitialradioelement application

76370 Computerized tomography guidance

76873 Determinate of prostate volume for brachytherapy

Reproductive Endocrinologists 76083 Digitization of radiographic images

76092 Screening mammography

76801-76857 Ultrasounds — pelvis

76820, 76821 Doppler velocimetry


76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation






Rheumatologists 72010-72120, 72170, 72190, Spine and pelvis imaging

72200-72220 Spine and pelvis imaging

73000-73140, 73500-73660 Imaging — upper and lower extremities

76000, 76003 Fluoroscopies

76040, 76066 Bone length studies, joint survey

76075, 76076, 0028T DEXA studies, bone densitometry

G0188 Full length radiography of lower extremity

Urologists 76870, 76872, 76873 Ultrasounds — echography, genitalia, bladder

76942 Ultrasonic guidance for needle biopsy

Imaging Requiring

Precertification

It is the responsibility of the referring physician, who has access to the patient’s complete medicalhistory, to contact CareCore National, LLC to requestprecertification and to provide sufficient history todemonstrate the appropriateness of the requested.

Radiology Precertification Policy for Urgent Cases It is the imaging facility’s responsibility to confirm that an authorization number has been issued prior toproviding a service. In the case of urgent examinations,in which there is no time to obtain an authorizationnumber and in cases in which, in the opinion of theattending physician, a change is required from theprecertified examination, the services may beperformed, and you may request a new or modifiedauthorization number. Please make your requests withintwo (2) business days of the date of service through theImaging Care Management Department in the usualmanner by calling or faxing your request. Clinicaljustification for the request will be reviewed using thesame criteria as a routine request.

Radiology Precertification OnlineCareCore now provides a secure web-based process to initiate clinical certification for diagnostic imagingrequests. Log onto www.carecorenational.com and the automated system will guide you through a series of computer screen prompts to collect routinedemographic data. Each web-initiated request isevaluated promptly by CareCore clinical review staff. A short return call to you from CareCore completes the certification process. This eliminates the need for a call to CareCore’s intake staff and allows you to enter multiple clinical certification requests at your convenience.



Radiology Utilization Review ProcessThe utilization review process involves matching thepatient clinical history and diagnostic information with the approved criteria for each imaging procedurerequested. Utilization review decisions are made byqualified health professionals including board certifiedradiologists. Data collection for clinical certification of imaging services may be assigned to non-medicalpersonnel working under the direction of qualifiedhealth professionals. You will receive notification ofreview determinations for non-urgent care by telephonewithin two (2) working days of receiving all the necessaryinformation. Notification for a determination involvingan urgent request is given within three (3) hours.

For non-urgent care requests for Oxford MedicareAdvantage® Members, a determination must be issuedwithin 14 calendar days of the request for service. For commercial Members, requests for retrospectiveclinical certification review of medically urgent care areaccepted up to two (2) business days after the care hasbeen given. Retrospective review decisions are madewithin 30 business days of receiving all of the necessaryinformation. If your request is not authorized, the review determination will be sent in writing to theMember and the requesting physician within five (5)business days of the decision.

Below is a list of imaging CPT codes that requireauthorization for commercial and Oxford MedicareAdvantage Members.

Please note: Oxford will inform you of any new proceduresor other changes to this list on the Oxford web page and in our quarterly Program and Policy Update.

To precertify a procedure, you can call CareCoreNational at 1-877-PRE-AUTH (1-877-773-2884), fax to845-298-1490 or log onto www.carecorenational.com.

When you call or fax a request to the RadiologyPrecertification unit, please provide the following information:

Patient Identifiers:

• Oxford ID number and health plan

• Name

• Date of birth

• Address

Medical Identifiers:

• Ordering doctor’s name and address

• Facility to which the patient is being referred and its address

• Contact person at your office

Clinical Information:

• Examination(s) being requested, with CPT codes if available

• Presumptive diagnosis or “rule out,” with ICD-9 codesif available

• Patient’s signs and symptoms, listed in some detail,with severity and duration

• Any treatments that have been tried, including dosageand duration for drugs and dates for other therapies

• Any other information that you believe will help inevaluating the request, including prior diagnostic tests,consultation reports, etc.

All authorization reference numbers are issued at thetime of approval. CareCore National uses the referenceCPT code as the last five (5) digits of the authorizationnumber. Please provide the authorization referencenumber to the imaging provider when scheduling the procedure.

Oxford requires the submission of clinical office notes for specific procedures. Clinical notes include the patient’s medical record and/or letters receivedfrom specialists that indicate:

• Patient symptoms, with duration and severity

• Patient medical history

• Previous imaging studies and findings

• Prior treatment and/or therapy, including surgery,with history

• Drug dosage prescribed and duration

Please note: Radiopharmaceuticals in excess of $50.00 willbe reimbursed. Submission of an invoice detailing the costand name of the administered material is still required.

If you choose to fax your authorization request, please include all of the information mentioned above, including the request form, to CareCoreNational at 845-298-1490.



CT Scans All CT units must be ACR accredited.

** Study requires the submission of clinical notes to CareCore National.

Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.

CPT Code Clinical Notes Required Description

70450 CT Head/Brain w/o Contrast

70460 CT Head/Brain w/Contrast

70470 CT Head/Brain w/o and w/Contrast

70480 CT Orbit w/o Contrast

70481 CT Orbit w/Contrast

70482 CT Orbit w/o and w/Contrast

70486 CT Maxllfcl w/o Contrast

70487 CT Maxllfcl w/Contrast

70488 CT Maxllfcl w/o and w/Contrast

70490 CT Soft Tissue w/o Contrast

70491 CT Soft Tissue w/Contrast

70492 CT Soft Tissue w/o and w/Contrast

70496 CT Angiography, Head

70498 CT Angiography, Neck

71250 CT Thorax w/o Contrast

71260 CT Thorax w/Contrast

71270 CT Thorax w/o and w/Contrast

71275 CT Angiography Chest

72125 CT C Spine w/o Contrast

72126 CT C Spine w/Contrast

72127 CT C Spine w/o and w/Contrast

72128 CT T Spine w/o Contrast

72129 CT T Spine w/Contrast

72130 CT T Spine w/o and w/Contrast

**72131 Yes CT L Spine w/o Contrast

**72132 Yes CT L Spine w/Contrast

**72133 Yes CT L Spine w/o and w/Contrast

72191 CT Angiography Pelvis



CT Scans (continued)


72192 CT Pelvis w/o Contrast

72193 CT Pelvis w/Contrast

72194 CT Pelvis w/o and w/Contrast

73200 CT Upper Extremity w/o Contrast

73201 CT Upper Extremity w/Contrast

73202 CT Upper Extremity w/o and w/Contrast

73206 CT Angiography Upper Extremity

73700 CT Lower Extremity w/o Contrast

73701 CT Lower Extremity w/Contrast

73702 CT Lower Extremity w/o and w/Contrast

73706 CT Angiography Lower Extremity

74150 CT Abdomen w/o Contrast

74160 CT Abdomen w/Contrast

74170 CT Abdomen w/o and w/Contrast

74175 CT Angiography Abdomen

75635 CT Angiography Abdominal Aorta

76013 X-ray Supervision and Interpretation, PercutaneousVertebralplasty Per Vertebral Body under CT Guidance

76362 CT Guidance for and Monitoring of Tissue Ablation

76380 CT Limited or Localized Follow-up Study

MRI Procedures All MRI units must be ACR accredited.

Please note: The information below is not to supersede any exceptions set forth by Oxford Health Plans.


70336 MRI TMJ

70540 MRI Face, Orbit, Neck w/o Contrast

70542 MRI Face, Orbit, Neck with Contrast

70543 MRI Face, Orbit, Neck w/and w/o Contrast

70551 MRI Head w/o Contrast



MRI Procedures (continued)


**70552 Yes MRI Head w/Contrast

**70553 Yes MRI Head w/and w/o Contrast

71550 MRI Chest w/o Contrast

71551 MRI Chest w/Contrast

71552 MRI Chest w/and w/o Contrast

**72141 Yes MRI Cervical Spine w/o Contrast

**72142 Yes MRI Cervical Spine w/Contrast

**72146 Yes MRI Thoracic Spine w/o Contrast

**72147 Yes MRI Thoracic Spine w/Contrast

**72148 Yes MRI Lumbar Spine w/o Contrast

**72149 Yes MRI Lumbar Spine w/Contrast

**72156 Yes MRI C Spine w/and w/o Contrast

**72157 Yes MRI T Spine w/and w/o Contrast

**72158 Yes MRI L Spine w/and w/o Contrast

72195 MRI Pelvis w/o Contrast

72196 MRI Pelvis w/Contrast

72197 MRI Pelvis w/and w/o Contrast

**73218 Yes MRI Upper Extremity other than Joint w/o Contrast

**73219 Yes MRI Upper Extremity other than Joint w/Contrast

**73220 Yes MRI Upper Extremity other than Joint w/and w/o Contrast

**73221 Yes MRI Upper Extremity Joint w/o Contrast

**73222 Yes MRI Upper Extremity Joint w/Contrast

**73223 Yes MRI Upper Extremity Joint w/ and w/o Contrast

**73718 Yes MRI Lower Extremity other than Joint w/o Contrast

**73719 Yes MRI Lower Extremity other than Joint w/Contrast

**73720 Yes MRI Lower Extremity other than Joint w/and w/o Contrast

**73721 Yes MRI Lower Extremity Joint w/o Contrast

**73722 Yes MRI Lower Extremity Joint w/Contrast

**73723 Yes MRI Lower Extremity Joint w/and w/o Contrast



MRI Procedures (continued)


74181 MRI Abdomen w/o Contrast

74182 MRI Abdomen w/Contrast

74183 MRI Abdomen w/and w/o Contrast

75552 Cardiac MRI for Morphology w/o Contrast (Gated Heart)

75553 Cardiac MRI Morphology w/Contrast

75554 Cardiac MRI Complete w/or w/o Morphology

75555 Cardiac MRI Limited

75556 Cardiac MRI Velocity Flow

**76093 Yes MRI Breast w/and/or w/o Contrast

**76094 Yes MRI Breast Bilateral

76390 MRI Spectroscopy

76393 MRI Guidance for Placement Radiological Supervision and Interpretation

76394 MRI Guidance for and Monitoring of Tissue Ablation

76400 MRI Bone Marrow Blood Supply

76499 Unlisted Procedure

MRA ProceduresCPT Code Description

70544 MRA Head w/o Contrast

70545 MRA Head w/Contrast

70546 MRA Head w/and w/o Contrast

70547 MRA Neck w/o Contrast

70548 MRA Neck w/Contrast

70549 MRA Neck w/and w/o Contrast

71555 MRA Chest (Exc. Myocardium) w/or w/o Contrast

72159 MRA Spinal Canal w/or w/o Contrast

72198 MRA Pelvis w/or w/o Contrast

73225 MRA Upper Extremity w/or w/o Contrast

73725 MRA Lower Extremity w/or w/o Contrast

74185 MRA Abdomen w/or w/o Contrast



PET Scans

All PET units must be ACR accredited.

** Study requires the submission of clinical notes to CareCore National.

Please note: Clinical notes are required for all PET scans.


**78459 Yes Myocardial Imaging, Positron Emission Tomography (PET)Metabolic Evaluation

**78491 Yes Myocardial Imaging, Positron Emission Tomography (PET),Perfusion; Single Study at Rest or Stress

**78492 Yes Myocardial Imaging, Positron Emission Tomography (PET),Perfusion; Multiple Studies at Rest or Stress

**78608 Yes Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation

**78609 Yes Brain Imaging, Positron Emission Tomography (PET)Metabolic Evaluation, Perfusion Evaluation

**78811 Yes Tumor Imaging, Positron Emission Tomography (PET);Limited Area (e.g., Chest, Head/Neck)

**78812 Yes Tumor Imaging, Positron Emission Tomography (PET); Skull Base to Mid-thigh

**78813 Yes Tumor Imaging, Positron Emission Tomography (PET); Whole Body

**78814 Yes Tumor Imaging, Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Limited Area (e.g., Chest, Head/Neck)

**78815 Yes Tumor Imaging, Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Skull Base to Mid-thigh

**78816 Yes Tumor Imaging, Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT)for Attenuation Correction and Anatomical Localization;Whole Body

**G0030 Yes PET Myocardial Perfusion Imaging; (Following PreviousPET, G0030-G0047); Single Study, Rest or Stress

**G0031 Yes PET Myocardial Perfusion Imaging; (Following PreviousPET, G0030-G0047); Multiple Studies, Rest or Stress

**G0032 Yes PET Myocardial Perfusion Imaging, (Following Rest/SPECT, 78464); Single Study, Rest or Stress



PET Scans (continued)


**G0033 Yes PET Myocardial Perfusion Imaging, (Following Rest SPECT,78464); Multiple Studies, Rest or Stress

**G0034 Yes PET Myocardial Perfusion Imaging, (Following SPECT,78465); Single Study, Rest or Stress

**G0035 Yes PET Myocardial Perfusion Imaging, (Following SPECT,78465); Multiple Studies, Rest or Stress

**G0036 Yes PET Myocardial Perfusion Imaging, (Following CoronaryAngiography, 93510-93529); Single Study, Rest or Stress

**G0037 Yes PET Myocardial Perfusion Imaging, (Following CoronaryAngiography, 93510-93529); Multiple Studies, Rest or Stress

**G0038 Yes PET Myocardial Perfusion Imaging, (Following Stress PlanarMyocardial Perfusion, 78460); Single Study, Rest or Stress

**G0039 Yes PET Myocardial Perfusion Imaging, (Following Stress Planar Myocardial Perfusion, 78460); Multiple Studies, Rest or Stress

**G0040 Yes PET Myocardial Perfusion Imaging, (Following StressEchocardiogram, 93350); Single Study, Rest or Stress

**G0041 Yes PET Myocardial Perfusion Imaging, (Following StressEchocardiogram, 93350); Multiple Studies, Rest or Stress

**G0042 Yes PET Myocardial Perfusion Imaging, (Following StressNuclear Ventriculogram, 78481 or 78483); Single Study, Rest or Stress

**G0043 Yes PET Myocardial Perfusion Imaging, (Following StressNuclear Ventriculogram, 78481 or 78483); Multiple Studies,Rest or Stress

**G0044 Yes PET Myocardial Perfusion Imaging, (Following Rest ECG,93000); Single Study, Rest or Stress

**G0045 Yes PET Myocardial Perfusion Imaging, (Following Rest ECG,93000); Multiple Studies, Rest or Stress

**G0046 Yes PET Myocardial Perfusion Imaging, (Following Stress ECG, 93015); Single Study, Rest or Stress

**G0047 Yes PET Myocardial Perfusion Imaging, (Following Stress ECG, 93015); Multiple Studies, Rest or Stress

**G0125 Yes PET Lung Imaging of Solitary Pulmonary Nodules, Using 2-(Fluorine-18) Fluoro-2-Deoxy-D-Glucose (FDG),Following CT (71250/71260 or 71270)





**G0210 Yes PET Imaging Whole Body; Diagnosis; Lung Cancer, Non-small Cell

**G0211 Yes PET Imaging Whole Body; Initial Staging; Lung Cancer,Non-small Cell

**G0212 Yes PET Imaging Whole Body; Restaging; Lung Cancer, Non-small Cell

**G0213 Yes PET Imaging Whole Body; Diagnosis; Colorectal Cancer

**G0214 Yes PET Imaging Whole Body; Initial Staging; Colorectal Cancer

**G0215 Yes PET Imaging Whole Body; Restaging; Colorectal Cancer

**G0216 Yes PET Imaging Whole Body; Diagnosis; Melanoma

**G0217 Yes PET Imaging Whole Body; Initial Staging; Melanoma

**G0218 Yes PET Imaging Whole Body; Restaging; Melanoma

**G0219 Yes PET Imaging Whole Body; Full and Partial Ring PETScanners Only, Non Covered Indications

**G0220 Yes PET Imaging Whole Body; Diagnosis; Lymphoma

**G0221 Yes PET Imaging Whole Body; Initial Staging; Lymphoma

**G0222 Yes PET Imaging Whole Body; Restaging; Lymphoma

**G0223 Yes PET Imaging Whole Body or Regional; Diagnosis; Head and Neck Cancer; Excluding Thyroid and CNS Cancers

**G0224 Yes PET Imaging Whole Body or Regional; Initial Staging; Headand Neck Cancer; Excluding Thyroid and CNS Cancers

**G0225 Yes PET Imaging Whole Body or Regional; Restaging; Head and Neck Cancer; Excluding Thyroid and CNS Cancers

**G0226 Yes PET Imaging Whole Body; Diagnosis; Esophageal Cancer

**G0227 Yes PET Imaging Whole Body; Initial Staging; Esophageal Cancer

**G0228 Yes PET Imaging Whole Body; Restaging; Esophageal Cancer

**G0229 Yes PET Imaging; Metabolic Brain Imaging for Pre-SurgicalEvaluation of Refractory Seizures

**G0230 Yes PET Imaging; Metabolic Assessment for Myocardial Viability Following Inconclusive SPECT Study

**G0231 Yes PET, Whole Body, for Recurrence of Colorectal Metastatic Cancer; Gamma Cameras Only





**G0232 Yes PET, Whole Body, for Recurrence of Lymphoma; Gamma Cameras Only

**G0233 Yes PET, Whole Body, for Recurrence of Melanoma; GammaCameras Only

**G0234 Yes PET, Regional or Whole Body, for Solitary PulmonaryNodule Following CT or for Initial Stating of Pathologically Diagnosed Non Small Cell Lung Cancer;Gamma Cameras Only

**G0252 Yes PET Imaging, Full and Partial Ring PET Scanners Only for Initial Diagnosis of Breast Cancer and/or SurgicalPlanning for Breast Cancer (e.g., Initial Staging of Ancillary Lymph Nodes)

**G0253 Yes PET Imaging for Breast Cancer, Full and Partial Ring PET Scanners Only, Staging/Re-staging of Local RegionalRecurrence or Distant Metastases (i.e., Staging/Re-stagingAfter or Prior to Course of Treatment)

**G0254 Yes PET Imaging for Breast Cancer, Full and Partial Ring PET Scanners Only, Evaluation of Response to TreatmentPerformed During Course of Treatment

Nuclear MedicinePlease note: All nuclear cardiology providers interpreting nuclear cardiology examinations are required to meet one of the following standards in order to receive reimbursement for nuclear cardiology claims:

• Certification by the Certification Board for Nuclear Cardiology (CBNC) 1

• Board certification in nuclear medicine by the American Board of Nuclear Medicine (ABNM)

• Board certification in radiology by the American Board of Radiology (ABR)

1 Nuclear cardiology facilities must be accredited by either the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL) or the American College of Radiology (ACR) in order to receive reimbursement for nuclear cardiology claims.

CPT Code Description

78000 Thyroid RAI Uptake

78001 Thyroid, Multiple Uptakes

78003 Thyroid Suppress or Stimulation

78006 Thyroid Uptake and Scan

78007 Thyroid, Image, Multiple Uptakes

78010 Thyroid Scan Only



Nuclear Medicine (continued)


78011 Thyroid Imaging with Flow

78015 Thyroid Met Imaging

78016 Thyroid Met Imaging with Additional Studies

78018 Thyroid Scan Whole Body

78020 Thyroid Carcinoma Metastases Uptake

78070 Parathyroid Nuclear Imaging

78075 Adrenal Nuclear Imaging

78099 Unlisted Endocrine Procedure, Diagnostic Nuclear Medicine

78102 Bone Marrow Imaging, Limited

78103 Bone Marrow Imaging, Multiple

78104 Bone Marrow Imaging, Whole Body

78110 Plasma Volume, Single

78111 Plasma Volume, Multiple Sampling

78120 Red Cell Volume Determination, Single Sampling

78121 Red Cell Volume Determination, Multiple Sampling

78122 Whole Blood Volume Determination, SEP Plasma and Red Cell

78130 Red Cell Survival Study

78135 Differential Organ/Tissues Kinetic

78140 Labeled Red Cell Sequestration

78160 Plasma Radioiron Disappearance

78162 Radioiron Oral Absorption

78170 Red Cell Iron Utilization

78172 Total Body Iron Estimation

78185 Spleen Imaging w and w/o VAS Flow

78190 Platelet Survival, Kinetics

78191 Platelet Survival

78195 Lymph System Imaging

78199 Unlisted Hematopoietic Diagnostic Nuclear Med

78201 Liver Imaging

78202 Liver Imaging with Flow





78205 Liver Imaging SPECT (3-D)

78206 Liver Imaging SPECT w/Vascular Flow

78215 Liver and Spleen Imaging

78216 Liver and Spleen Imaging with Flow

78220 Liver Function Study

78223 HIDA Scan

78230 Salivary Gland Imaging

78231 Serial Salivary Gland

78232 Salivary Gland Function Exam

78258 Esophageal Motility Study

78261 Gastric Mucosa Imaging

78262 Gastroesophageal Reflux Exam

78264 Gastric Emptying Study

78270 VIT-B12 Absorption Exam

78271 VIT-B12 Absorption Exam, lF

78272 VIT-B12 Absorption Exam Combined

78278 GI Bleeder Scan

78282 GI Protein Loss Exam

78290 Meckel’s Diverticulum Imaging

78291 Leveen Shunt Patency Exam

78300 Bone or Joint Imaging LTD

78305 Bone or Joint Imaging Multiple

78306 Bone Scan Whole Body

78315 Bone Scan 3-Phase Study

78320 Bone Joint Imaging Tomo Test

78399 Unlisted Musculoskeletal

78414 Non-Imaging Heart Function

78428 Cardiac Shunt Imaging

78445 Radionuclide Venogram Non-Cardiac





78455 Venous Thrombosis Study

78456 Acute Venous Thrombosis Imaging

78457 Venous Thrombosis Imaging Unilateral

78458 Venous Thrombosis Images, Bilateral

78460 Thallium Scan Rest Only

78461 Myocardial Perf Stress or Rest Multiple Study

78464 Heart Image (3-D) Single

78465 Myocardial Perf w/SPECT Multiple

78466 Myocardial Infarction Scan

78468 Heart Infarct Image EF

78469 Heart Infarct Image 3-D

78472 Gated Heart, Resting

78473 Cardiac Blood Pool Muga Scan

78481 Heart First Pass Single

78483 Cardiac Blood Pool Imaging — Multiple

78494 Cardiac Blood Pool Imaging, SPECT

78496 Cardiac Blood Pool Imaging — Single Study at Rest (Use with 78472)

78499 Unlisted Cardiovascular Nuclear Exam

78580 Pulmonary Perfusion Imaging

78584 Pulmonary Perfusion with Vent Single Breath

78585 Pulmonary Perfusion w/Washout, w/or w/o Single Breath

78586 Pulmonary Ventilation Imaging

78587 Pulmonary Ventilation Multi

78588 Pulmonary Perfusion w/Ventilation

78591 Vent Image 1 Breath, 1 Projection

78593 Vent Image 1 Projection, Gas

78594 Vent Image Multi Projection, Gas

78596 Lung Differential Function

78599 Unlisted Respiratory Nuclear Exam

78600 Brain Imaging LTD Static





78601 Brain LTD Imaging and Flow

78605 Brain Imaging Complete

78606 Brain Imaging Complete with Flow

78607 Brain Imaging 3-D

78610 Brain Flow Imaging Only

78615 Cerebral Blood Flow Imaging

78630 Cisternogram (Cerebrospinal Fluid Flow)

78635 Cerebrospinal Ventriculography

78645 CSF Shunt Evaluation

78647 Cerebrospinal Fluid Scan

78650 CSF Leakage Detection and Localization

78660 Radiopharmaceutical Dacryocystography

78699 Unlisted Diagnostic Nuclear Med Procedure

78700 Kidney Imaging (Static)

78701 Kidney Imaging w/Vascular Flow

78704 Kidney Imaging w/Function Study

78707 Kidney Imaging w/Vascular Flow and Functional Single Study

78708 Kidney Imaging Single Study w/Pharm. Intervention

78709 Kidney Imaging — Multiple Studies w/ and w/o Pharm. Intervention

78710 Kidney Imaging — Tomographic (SPECT)

78715 Kidney Vascular Flow Only

78725 Kidney Function Study — Non-Imaging Radioisotopic

78730 Urinary Bladder Residual Study

78740 Ureteral Reflux Study

78760 Testicular Imaging

78761 Testicular Imaging w/Vascular Flow

78799 Unlisted Genitourinary Procedure

78800 Radiopharm Localization of Tumor, Limited Area

78801 Radiopharm Localization of Tumor, Multiple Areas





78802 Radiopharm Localization of Tumor, Whole Body

78803 Radiopharm Localization of Tumor Tomographic (SPECT)

78804 Radiopharm Localization of Tumor or Distribution of Radiopharm Agents; Whole Body

78805 Radiopharm Localization of Abscess, Limited Area

78806 Radiopharm Localization of Abscess, Whole Body

78807 Radiopharm Localization of Abscess, Tomographic SPECT

78999 Unlisted Misc. Procedure

Obstetrical Ultrasounds

Authorization required for fourth and subsequent procedures.

Please note: OBGYNs must have AIUM or ACR accreditation in order to be reimbursed for CPT codes 76801, 76802,76805, 76810, 76818, 76819, 76820, 76821, 76825, 76826, 76827, and 76828


76801 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation, First Trimester (<14 Weeks 0 Days),Transabdominal Approach; Single or First Gestation

76802 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation, First Trimester (<14 Weeks 0 Days), TransabdominalApproach; Each Additional Gestation (List separately in addition to Code for Primary Procedure Performed) [Use 76802 in conjunction with 76801]

76805 Echography, Pregnant Uterus, B-Scan and/or Real Time w/ImageDocumentation, Complete Fetal and Maternal Evaluation

76810 Complete — Fetal and Maternal Evaluation, Multiple Gestation, after the First Trimester

76811 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination,Transabdominal Approach; Single or First Gestation

76812 Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation Plus Detailed Fetal Anatomic Examination,Transabdominal Approach; Each Additional Gestation (List separately in addition to Code for Primary Procedure Performed) [Use 76812 inconjunction with Code 76811]

76815 Limited — Fetal Size, Heart Beat, Placental Location, Fetal Position or Emergency in the Delivery Room



Obstetrical Ultrasounds (continued)


76816 Follow-up or Repeat

76817 Ultrasound, Pregnant Uterus, Real Time with Image Documentation,Transvaginal [For Non-obstetrical Transvaginal Ultrasound, use 76830] [If Transvaginal Examination is done in addition to Transabdominal Obstetrical Ultrasound Exam, use 76817 in addition to appropriateTransabdominal Exam Code]

76818 Fetal Biophysical Profile

76819 Fetal Biophysical Profile; Without Stress or Non-stress Testing

76820 Doppler Velocimetry, Fetal; Umbilical Artery

76821 Doppler Velocimetry, Fetal; Middle Cerebral Artery

76825 Echocardiography, Fetal, Cardiovascular System, Real Time w/ImageDocumentation (2d), w/or w/o M-Mode Recording

76826 Follow-up or Repeat Study

76827 Doppler Echocardiography, Fetal, Cardiovascular System, Pulsed Wave and/or Continuous Wave w/Spectral Display, Complete

76828 Follow-up or Repeat Study

76975 Endoscopic Ultrasound

Physical and Occupational Therapy

OrthoNet, a musculoskeletal disease managementcompany, is Oxford’s network manager for mostcommercial outpatient physical and occupationaltherapy services. OrthoNet is a local company with an office in White Plains, New York. Physical andoccupational therapy provided by a chiropractor is managed by TRIAD Healthcare, Inc.

Most commercial physical and occupational therapyservices following the initial evaluation (CPT codes97001 and 97003) in the CPT code list below require an OrthoNet authorization (chiropractors should refer to Chiropractic Guidelines in this section). A referral is required for the initial evaluation(excludes non-gatekeeper Members). Providers will receive a response by fax. The goal is to provideresponses within two (2) business days of receipt of all required clinical documentation. The CPT codeslisted on the following page require utilization review.



Authorization requests can be made by faxing the necessary documentation to OrthoNet at 1-800-216-0810.

For urgent requests or inquiries about clinical care, treatment plans, status, and outcomes, call the OrthoNet Medical Management Department at 1-800-201-4872.

For PCPs, there are no changes to the current Oxfordreferral process for the first therapy visit (CPT codes97001 and 97003); simply refer the Member. Do notindicate the number of visits for which the Member is approved, since that will be determined as part of the utilization review process.

Please note: Electronic referral receipts, which show thenumber of visits, cannot be used in lieu of OrthoNet’sauthorization. All visits beyond the initial evaluations muststill be precertified with OrthoNet regardless of the number of visits that may be listed on the electronic referral receipt.

For providers of physical and occupational therapy,there are no changes to the existing claims submissionprocess or the Oxford fee schedule. Remember thatfailure to comply with the new medical managementpolicy for therapy services after the initial evaluationmay result in non-payment.

If you have any questions on how to obtain thenecessary forms, please call OrthoNet’s ProviderServices Department at 1-800-201-4891.

CPT Codes Requiring OrthoNet Precertification* Cannot be billed by an occupational therapist (also applies to CPT code 97001).


*97002 Physical therapy re-evaluation

97004 Occupational therapy re-evaluation

97010 Application of a modality — does not require direct patient-provider contact, hot or cold packs

*97012 Application of a modality — does not require direct patient-provider contact, traction — mechanical

97014 Application of a modality — does not require direct patient-provider contact, electricalstimulation (unattended)

97016 Application of a modality — does not require direct patient-provider contact, vasopneumatic devices

97018 Application of a modality — does not require direct patient-provider contact, paraffin bath

97020 Application of a modality — does not require direct patient-provider contact, microwave

97022 Application of a modality — does not require direct patient-provider contact, whirlpool

*97024 Application of a modality — does not require direct patient-provider contact, diathermy

*97026 Application of a modality — does not require direct patient-provider contact, infrared

*97028 Application of a modality — does not require direct patient-provider contact, ultraviolet

*97032 Application of a modality — requires direct patient-provider contact, electrical stimulation (manual)

*97033 Application of a modality — requires direct patient-provider contact, iontophoresis



CPT Codes Requiring OrthoNet Precertification (continued)


97034 Application of a modality — requires direct patient-provider contact, contrast baths

*97035 Application of a modality — requires direct patient-provider contact, ultrasound

*97036 Application of a modality — requires direct patient-provider contact, Hubbard tank

97039 Application of a modality — requires direct patient-provider contact, unlisted modality (specify)

97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112 Neuromuscular re-education of movement

*97113 Aquatic therapy with therapeutic exercises

97116 Gait training (included stair climbing)

97124 Massage, including effleurage, petrissage and/or tapotement

97139 Unlisted therapeutic procedure (specify)

97140 Manual therapy techniques, one or more regions

97150 Therapeutic procedures, group (2 or more individuals)

97504 Orthotics, fitting and training, upper and/or lower extremities

97520 Prosthetic training, upper and/or lower extremities

97530 Therapeutic activities — direct patient-provider contact, use of dynamic activities to improve functional performance

97532 Development of cognitive skills to improve attention, memory, problem solving

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands

97535 Self-care/home management training — direct patient-provider contact

97537 Community/work re-integration training — direct patient-provider contact

97542 Wheelchair management/propulsion training

97545 Work hardening/conditioning, initial 2 hours

97546 Work hardening/conditioning, each additional hour

97703 Checkout for orthotic/prosthetic use, established patient

97750 Physical performance test or measurement

97799 Unlisted physical medicine/rehabilitation service or procedure

G0151 Services of physical therapist in home health setting, each 15 minutes

G0152 Services of occupational therapist in home health setting, each 15 minutes

G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care



Acupuncture andChiropractic Guidelines

Acupuncture Guidelines

Oxford covers acupuncture as a benefit only for thoseMembers who have the alternative medicine rider, andwill deny all requests for acupuncture if the rider is notpart of the Member’s benefit package, even if a letter of medical necessity has been submitted.

Acupuncture is covered for commercial Members onlyon an in-network basis and must be performed by oneof following provider types:

• Participating licensed acupuncturist (LAC)

• Participating licensed naturopaths

• Participating physician (MD or DO) who has been credentialed as physician acupuncturist

Chiropractic Guidelines

To receive the standard chiropractic benefit coverage,Members must obtain an electronic referral from theirPCP. Under Oxford’s Complementary & AlternativeMedicine (CAM) Program, choosing a chiropractor iseasy, as Oxford has an extensive network of credentialedchiropractors throughout your service area.

To help facilitate referrals for chiropractic care, Oxfordhas developed the following guidelines, which are basedon current medical literature.1 PCPs should perform thecustomary initial comprehensive differential diagnosiswith the necessary and appropriate work-up.

For patients with conditions that may respond well to chiropractic care, such as acute low back pain, neck pain or other neuromusculoskeletal problems,you should discuss conventional and chiropractic treatment options with your patient, describing the risks and benefits of each. If a patient requests a referral to a chiropractor and there is no compellingmedical contraindication, you can make the referral for an initial evaluation.

1 Meeker, W.C.; Haldeman, S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. [Review] [164 refs] [HistoricalArticle. Journal Article. Review. Review, Academic] Annuals of InternalMedicine. 136(3): 216-27, 2002 Feb 5.

For commercial Members only: One visit within 180days (six months) is the maximum number of visits forwhich a chiropractic referral can be generated. Oxfordrequires all participating chiropractors to submit aninitial care plan (ICP) to TRIAD Healthcare, Inc. forservices performed beyond the initial evaluation visit.You will need to obtain approval of the plan as acondition of reimbursement for subsequent visits.

Chiropractic services can be precertified bycompleting an initial care plan (ICP) and faxing it directly to TRIAD at 1-866-225-1033.

An ICP must be submitted to TRIAD within 14 businessdays following the patient’s initial evaluation, or priorto the second visit, whichever occurs first. The careplan must include the initial visit. If TRIAD does not receive an ICP within this time frame, your claim will be denied. Once the completed ICP isreceived, TRIAD will review the services requested for medical necessity, and Oxford will make any denialdeterminations. If a patient’s care requires additionalvisits or more time than was precertified on the ICP,you may submit an extension of care (EOC) form after the initially approved visits have occurred.

Please note: According to your contract with Oxford, if services are not precertified and claims are denied, you cannot bill the patient for these services. However, you may file an appeal.

For Oxford Medicare Advantage® Members: Theinitial referral is valid for one visit. Coverage ofchiropractic care is limited to treatment by means ofmanual manipulation of the spine for the purpose ofcorrecting an acute subluxation. No other diagnostic or therapeutic service (including but not limited tomodalities, laboratory services, radiology) furnished by a chiropractor or under his/her order is covered.

After the first visit, the chiropractor will fax a care plan to Oxford’s Complementary & AlternativeMedicine Department at 1-800-201-7025.

The care plan will be thoroughly reviewed by anexperienced chiropractic reviewer, who will deny or approve the plan based on the appropriate number of visits for treatment. The PCP shouldschedule a follow-up visit or phone call with the patient to monitor progress.



Absolute Contraindications to Chiropractic Care

• Vertebral malignancy

• Infection or inflammation

• Cauda equina syndrome

• Myelopathy or severe spondylosis

• Multiple adjacent radiculopathies

• Vertebral bone diseases

• Vertebral bony joint instability (e.g., fractures, dislocations)

• Rheumatoid disease in the cervical region

Relative Contraindications

• Presence of spinal deformity and most skeletal anomalies

• Systemic anticoagulation, either disease-related or pharmacologic severe diabetes

• Atherosclerosis

• Severe degenerative joint disease

• Vertigo or symptoms and signs of vertebral-basilarartery disease or insufficiency

• Spondyloarthropathies (e.g., psoriatic, ankylosingspondylitis, Reiter syndrome)

• Inactive rheumatoid disease

• Ligamentous joint instability or congenital joint laxity

• Syndromes such as Marfan and Ehlers-Danlos

• Aseptic necrosis

• Local aneurysm

• Osteomalacia

• Osteoporosis

Pharmacy

Pharmacy Benefit Manager

Medco Health Solutions, Inc. (Medco) is Oxford’spharmacy benefit manager. Medco has a dedicatedservice line to address all physician questions. This line is available 24 hours a day, seven days a week(excluding Thanksgiving and Christmas Day).

To contact Medco, please call 1-800-905-0201.

Pharmacy and

Therapeutics Committee

The Pharmacy and Therapeutics Committee (P&T Committee) provides direction and establishespolicies and procedures related to the delivery ofpharmaceutical products to Oxford Members. The P&T Committee is responsible for developing and updating Oxford’s policies and procedures for pharmaceutical management including overseeing all pharmacy-related quality managementactivities, making recommendations and providing



final approvals, as well as ongoing evaluation of any formularies and clinical management programs used by Oxford. The P&T Committee meets quarterly, and is composed of Oxford MedicalDirectors, participating plan physicians from various medical specialties and, pharmacists.Appropriate specialists are consulted as necessary.

Pharmacy Management

Programs

Oxford’s prescription drug plan is comprised of a comprehensive package of benefits that includes a complete drug formulary and pharmacy management programs. These programs are updated as new drug products are approved by the Food and Drug Administration (FDA) or when new pharmaceutical information becomes available.

Along with benefit changes, Oxford will continue toimplement clinical pharmacy management programsthat are designed to improve quality of care and tobetter manage costs by reducing drug and hospitalexpenses incurred through unnecessary drug use and waste, and by limiting exposure to medical costs due to adverse drug reactions. Together with Medco, Oxford has established programs toencourage drug therapy that is appropriate andeconomical for our Members. These programs arelargely based on guidelines established by the FDA.

Quality Management and Patient Safety Programs

Drug Utilization Review (DUR)

Pharmacists submit almost all prescriptionselectronically. Within seconds, the Member’s claimregisters and the past prescription history is reviewedfor potential drug-related problems. DUR helpssafeguard patients from potentially harmful druginteractions, overutilization and other adverse drugevents in an effort to maximize therapy effectivenesswith the appropriate drug and dosing parameters.

There are two types of DUR programs, concurrent and retrospective:

1) Concurrent DUR

Concurrent DUR (CDUR) is a point-of-sale, system-based review process that screens theincoming prescription for a broad range of safety considerations, prior to dispensing, bycomparing the prescription to the patient’s drug history. The system helps identify potentialdrug utilization issues and sends an alert to thedispensing pharmacists to reduce patient risk ofadverse drug events, improve quality of care andreduce any unnecessary costs. There are two types of alert messages:

Warning alert — sends an online warning message tothe pharmacists. Examples of warning alerts include:

• Drug interaction

• Underutilization

• Duplicate therapy

• Drug-allergy

• Drug-gender

• Drug-disease

• Drug-age

• Drug-pregnancy

• Under minimum

• Look-alike/sound-alike daily dose

Reject alert — the claim is rejected at the point-of-sale, which prevents the prescription claim frombeing paid. Examples of reject alerts include:

• Early refill (refill too soon)

• Maximum daily dose (over maximum dose)

• Cyclic max dose

• Severe drug interaction



2) Retrospective DUR

Retrospective DUR (RDUR) is a quarterly reviewthat alerts physicians to drug utilization issues that warrant their considerations. These reviews are designed to provide physicians with timely,relevant information so that physicians can prescribe the right drug at the right dose for the right amount of time.

RDUR functions by focusing on the categories and drugs that are most likely to be prescribed or used inappropriately. Claims are reviewed toidentify patterns of inappropriate prescribing andconsumption that do not comply with best clinicalpractices. Physicians are informed of potential issues and opportunities, and are provided clinicalconsiderations for reference. Physicians are providedwith patient-level data that they might not normallyhave access to along with clinical considerations.Physician satisfaction and acceptance are tracked,and changes in therapy are identified and reportedbased on subsequent claims information. Examplesof RDUR include dose considerations with non-steroidal anti-inflammatory drugs (NSAIDs),migraine therapy and prophylaxis, and dose and duration considerations with an H2-receptorantagonist (H2RA)/proton pump inhibitor (PPI).

RDUR contributes to improved care by helpingphysicians safeguard patients against potentiallyinappropriate utilization and harmful interactions,promoting awareness of clinically-based guidelinesand plan policies, and better managing costs.

FDA Alerts and Product Recalls

Oxford’s pharmacy benefit manager (PBM) has aformal process to address FDA and manufacturer drugrecall designed to ensure that the health and safety ofpatients is considered with every event. Where possible,patients affected by FDA-required or voluntary drugwithdrawals are identified and notified by mail. Patientsare provided the drug product lot numbers affected by the recall and asked to share this information withtheir physician or other healthcare professional.Patients are instructed on where to send the recalledproduct received from the PBM. Information on drugrecalls is also posted on the PBM’s web site.

Controlled Drug Use Evaluation (DUE)

The objective of DUE is to promote medicallyappropriate drug therapy for our Members. On aquarterly basis, Oxford reviews the medication profilesof Members who receive frequent prescriptions fornarcotic analgesics and other controlled drugs at highdoses. Members are identified based on the repetitiveuse of an anxiolytic, barbiturate sedative/hypnotic ornarcotic analgesics in doses and/or quantities over 120days, which may indicate overutilization through eitheran excessive daily dose (misuse) or prescriptions frommultiple physicians (abuse) without therapeutic benefitto the patient. Oxford will notify you by mail if anypatients for whom you prescribe controlled drugs meet these criteria. This notification letter is intendedto provide information and, when indicated (in youropinion), help modify your patient’s drug use behavior.If you are contacted, please review this informationcarefully to verify that your patient is taking themedication according to your instructions.

Utilization ManagementEnsuring that patients receive the appropriate drug at the right dose for the length of time necessary totreat a particular medical condition is key to providingappropriate pharmacy care. Guidelines for diagnosisand treatment for some of the most common chronicconditions have been established by the FDA and othergovernment and medical subspecialty societies.

Medications Requiring Precertification

Based on plan designs, selected high-risk or high-costdrugs may require precertification by Oxford in orderto be eligible for coverage. Precertification criteria have been established by the P&T Committee withinput from plan physicians and considerations of thecurrent medical literature. For most Members withpharmacy benefit coverage through Oxford, themedications on the following list (including theirgeneric equivalent, if available) generally requireprecertification through Medco, based on Oxford’scoverage criteria. Precertification (also known as priorauthorization) requires that you formally submit arequest to, and receive approval from, Medco in orderfor the Member to receive coverage for a prescriptionfor certain medications.



You may be asked to provide information explainingmedical necessity and past therapeutic failures. Arepresentative will collect all pertinent clinical data for the service requested. For those requests that do not meet the criteria for approval, you will beinformed that the coverage determination requiresfurther review by an Oxford Medical Director.Notification of decisions is made within one (1)business day of receipt of the request. If the necessaryinformation required to render a decision is notreceived with your initial request, the information willbe requested within 24 hours of receipt of the request.

If you have any questions regarding the medicationson this list or any other medications, please callPharmacy Customer Service at 1-800-905-0201.

Medications Requiring Precertification(subject to plan design)

Endocrine drugs

• Anadrol — 50*

• Androderm patches*

• Androgel*

• Android*

• Calderol

• Deca Durabolin*

• Delatestry1*

• Depo Testosterone*

• DHT

• Halotestin*

• Hytakero1

• Methyltestosterone*

• Oxandrin*

• Rocaltrol

• Somavert3

• Striant*

• Testim*

• Testoderm*

• Testosterone*

• Testred*

• Winstrol*

• Zavesca3

Dermatological drugs

• Avita2

• Differin2

• Elidel*

• Protopic*

• Raptiva3

• Retin A2

Gastrointestinal drugs

• Aciphex*

• Lotronex*

• Nexium*

• Prevacid*

• Prilosec*

• Protonix*

• Zegerid*

• Zelnorm*

Growth hormones

• Serostim

Musculoskeletal and rheumatological drugs

• Bextra*

• Celebrex*

• Enbrel3

• Forteo

• Humira

• Kineret



Medications Requiring Precertification (continued)

OB/GYN drugs

• Lupron (3.75 mg and 11.25 mg)

Psychotherapeutic drugs

• Adderall1

• Concerta1

• Desoxyn1

• Dexedrine1

• Dextrostat1

• Provigil

• Strattera

Pulmonary drugs

• Singulair4*

Urological drugs

• Caverject**

• Cialis**

• Edex**

• Levitra**

• Muse**

• Viagra**

Vitamins/Nutritional products

• Drisdol

• Hectorol

• Nutritional therapies3

1 Applies only to Members age 19 or older


3 For coverage information, Members call our Customer Service Departmentat the number on their Oxofrd ID card


* Precertification is not required for Oxford Medicare Advantage® Members

** Medication is not covered for Oxford Medicare Advantage Members

Please note: Precertification requirements may varydepending on the Member’s benefits. This list is subject to change without notice.

To obtain precertification, please call Medco directly at 1-800-753-2851, Mon. - Fri. 8 AM to 9 PM

(Eastern Standard Time).

Step TherapyBased on plan design, selected medications may require step therapy to be eligible for coverage. In step therapy, the plan requires the use of genericdrugs before it will cover certain brand drugs. Thesegeneric drugs are approved by the FDA and are used to treat the same conditions as the brand drug. Steptherapy requires that you formally submit a request to, and receive approval from, Medco in order for the Member to receive coverage for a prescription for certain medications.

Quantity LimitsFor certain medications, and based on plan design, a limitation in the quantity covered at one timeis in place, often reflecting the maximum FDA-recommended dosage for a drug or use of the most efficient drug strength for the fully prescribeddaily dose. In these situations, an electronic messagespecifying quantity limits will be sent to the pharmacistinstructing that the prescription be reviewed with the prescribing physician. In all cases, the goal is to encourage medically appropriate and economicaluse of drugs.



Three-tier Prescription Drug Benefit

Oxford has a three-tier prescription drug benefit available for many commercial and Oxford Medicare Advantage®

plans. As of January 1, 2005, we transitioned to UnitedHealthcare’s Prescription Drug List. The Prescription DrugList for this benefit was carefully designed to promote medically appropriate, cost-effective healthcare whilepreserving your ability to prescribe specific drugs of choice for your patients. The three tiers include generic drugs (Tier 1), preferred brand drugs (Tier 2) and non-preferred brand drugs (Tier 3), with an increase in copayment(cost share) to our Members with each tier. Members covered by the three-tier prescription plan benefit may haveone of the following plan designs, depending on the benefit chosen by their employer:

Plan Design* Tier 1: Tier 2: Tier 3: Generic Drugs Preferred Brand Drugs Non-Preferred Brand Drugs

Rx Plan A copayments $5 $15 $35

Rx Plan B copayments $5 $15 $50

Rx Plan C copayments $7 $20 $50

Rx Plan D copayments $5 $10 $20

Rx Plan E copayments $7 $15 $35

Rx Plan F copayments $10 $20 $50

* Plan designs are not available in all states. Not all Members have a three-tier pharmacy benefit: Oxford Medicare Advantage may have either no pharmacybenefit, a generic drug only benefit or a three-tier pharmacy benefit.

Please note: This is not a complete listing. This three-tier drug benefit structure may be extended to other groups. Please refer to our Program and Policy Update for any changes.

You may continue to choose from the many qualitydrugs available, using your patient’s out-of-pocket cost as a consideration when prescribing.

Please note: Certain New York plans include a mandatorygeneric program. This means that if there is a genericequivalent available for the prescribed drug, the Memberwill only be covered for the generic drug. If the Memberpurchases a brand drug when a generic drug is available,they will be responsible for the full cost of the brand drug.If there is no generic equivalent available for the prescribeddrug, the Member will be covered for the brand drug.

Please review the Prescription Drug List and, whereappropriate for your patients, consider changing Tier 3 prescriptions to generic or preferred branddrugs. Look for Oxford’s complete drug formulary at www.oxfordhealth.com.

Please note: This three-tier drug benefit structure may be extended to other groups. Please refer to our Programand Policy Updates for any changes.

Mail Order Through Medco

By Mail

Oxford offers Members the ability to obtain up to a 90-day supply of certain medications within severaltherapeutic categories of medications through MedcoBy Mail. Maintenance medications are prescriptionmedications associated with the treatment of certainchronic conditions, such as diabetes, hypertension and epilepsy. All Members whose plans include themail-order benefit are entitled to use Medco By Mail.



Please note: Mail-order coverage may vary depending on the Member’s benefit. Please refer to the Member’sCertificate of Coverage or Prescription Drug Rider forspecific coverage information. Not all Members have a plan that includes mail-order coverage.

Medco By Mail P.O. Box 747000Cincinnati, OH 45274-7000

For more information on specific drug coveragethrough Medco By Mail, please call PharmacyCustomer Service at 1-800-905-0201.

The Prescription Drug List

As of January 1, 2005, Oxford transitioned toUnitedHealthcare’s Prescription Drug List. The Prescription Drug List is a dynamic listing of medications that is reviewed at least annually and updated quarterly to reflect advances in medical care. Quarterly updates appear in the Program and Policy Update. Also available atwww.oxfordhealth.com, the drug list details inclusions,generic and preferred brand drugs, drug quantitylimits, and precertification requirements.

Please note: The listing of a drug product does notguarantee coverage, as certain products are excluded due to benefit plan design limitations that are specific to Member’s individual or group benefits. In addition,diabetic supplies that are available through the Member’sbase medical benefit are subject to the applicable office visit copayment (cost share) noted on the Member’sSummary of Benefits.

The Prescription Drug List includes generic andpreferred brand drugs. If a brand name drug is not listed, it is a non-preferred brand drug and subject to the three-tier pharmacy benefit (if the Member has a three-tier benefit). The list isalphabetized by the name of the drug. Generic drugs are listed in lower case letters and preferredbrand drugs are listed in CAPITAL letters. Drugsaffected by quantity limits are preceded by an asterisk (*). Drugs requiring precertification aredesignated as (PAR).

Please note: The Prescription Drug List is subject tochange. Any changes will be posted in the quarterlyProgram and Policy Update. For Members with a three-tier pharmacy benefit, changes in the tier status of a drug may also change the Member’s out-of-pocketexpense for that drug.

OOXF O R D | I M PO RTA NT A D D R ES S

ancillary services

Documents